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Mental Status Examination: Identification Data

Mr. Xxx is a 33-year-old male who has been diagnosed with alcohol dependence syndrome. He presents with increased psychomotor activity, spontaneous and coherent speech with relevant content. His affect is appropriate to his depressed mood. He has no formal thought disorder or hallucinations. He is oriented to place and person but has poor attention, concentration, and recent and remote memory. His intelligence and abstraction abilities are impaired. His insight is absent.

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4K views5 pages

Mental Status Examination: Identification Data

Mr. Xxx is a 33-year-old male who has been diagnosed with alcohol dependence syndrome. He presents with increased psychomotor activity, spontaneous and coherent speech with relevant content. His affect is appropriate to his depressed mood. He has no formal thought disorder or hallucinations. He is oriented to place and person but has poor attention, concentration, and recent and remote memory. His intelligence and abstraction abilities are impaired. His insight is absent.

Uploaded by

ilakkiya ilakkiya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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MENTAL STATUS EXAMINATION

IDENTIFICATION DATA:
Name : Mr. Xxx

Age : 33 Yrs

Sex : male

Ip. No: 31234

Ward : 211

Address:

Education:

Occupation:

Income:

Marital status:

Religion:

DIAGNOSIS : ALCOHOL DEPENDENCE SYNDROME

I. GENERAL APPEARANCE AND BEHAVIOR:


Attitude-Cooperative rapport established and sustained
Grooming- Well groomed
Facial expression- Eye to eye contact poor.
Posture- Strained
Gait carriage- Body erect normal
Body built- Thin and lean

2. PSYCHOMOTOR ACTIVITIES
Increased .

3. SPEECH:
Nurse : How are you?
Patient: (so actively) …. Very fine sister.

INFERENCE:
Tone: increased
Tempo: increased
Volume: increased
Spontaneity: spontaneous
Productivity: normal
Reaction time: decreased
Coherent: coherent
Relevance: relevant

4. MOOD AND AFFECT:

NURSE:” How do you feel?”


PATIENT: She was fine and looks happy.
INTERENCE
The affect is appropriate to the mood.

5. THOUGHT
NURSE: Why you came here?
PATIENT : My wife was died last month. I love here so much. So I came here.
NURSE : How she died?
PATIENT : She suicide.
INFERENCE
Form: No formal thought disorder.
Stream: No filght of ideas, circumstantiality, preservation.
Content: Depressive ideadation and sucide ideas.
Possessions: No obsessions and compulsions, thought alienation.

6. PERCEPTION:

A) ILLUSIONS
Nurse: What is this?
Patient: It’s a pen.
INFERENCE:
Illusions absent.

B) AUDITORY HALLUCINATION
Nurse: Do you hear any voices ?
Patient: No.
INFERENCE:
Auditory hallucination absent

C) VISUAL HALLUCINATION
Nurse: Did you saw any person coming nearby you?
Patient : No
INFERENCE:
Visual hallucination absent
D) TACTILE OR GUSTATORY HALLUCINATION
Nurse: Do you feel any itching or bad smell?
Patient: No
INFERENCE:
Tactile or gustatory hallucination absent.

7. COGNITIVE FUNCTIONS:

Consciousness : Patient was conscious and alert

A) ORIENTATION:
Nurse: what is the time?
Patient: Don’t know
Nurse: where are you now?
Patient: NIMHANS hospital
Nurse: (pointing one of the staff) who is this?
Patient: sister.
INFERENCE;
He is oriented to place and person.

B) ATTENTION AND CONCENTRATION:


Digit span test up to 4 digits forward and 6 digit back wards
Serial subtraction could subtract 20-1 should reverse in 15 secs.
INFERENCE:
His attention and concentration is poor.

C) MEMORY:

a) Immediate memory
Nurse : What is your name?
Patient : Manjunath

b) Recent memory
Nurse : What you did yesterday evening?
Patient : Don’t know

c) Remote
Nurse : When is your birthday?
Patient : Don’t know

INFERENCE
Immediate memory : Present
Recent memory : Absent
Remote : Absent
D) INTELLIGENCE:

1. GENERAL INFORMATION:
Nurse: who is the chief minister of Karanataka?
Patient: No
Nurse: Who is the Father of our Nation?
Patient: Gandhji
Nurse: What is the importance of January 26?
Nurse: Independent day
INFERENCE
Poor intelligence
2. COMPREHENSION
Nurse: What will you do when you feel cold?
Patient: I will wear suitor.
Nurse: What will you do if it rains when you start to work?
Patient: Wait for sometimes.
INFERENCE: Good comprehension.

3. ARITHMETIC:
Addition: 42+2=44
Subtraction:50-5=45
Multiplication:14x4= 56
Division:24/2= 12
INFERENCE:
Arithmetic functions are intact.

4. ABSTRACTION:
Nurse: Similarities between orange and banana
Patient: They are fruits
Dissimilarities:
Nurse: Difference between orange and potato?
Patient: Orange is a fruit and potato is a vegetable.
INFERENCE: He can able to tell similarities and dissimilarities.

5. PROVERB:
Nurse: Can you explain about “Slow and steady race the win?
Patient: I don’t know all that.
INFERENCE:
Abstraction absent at the concrete level.

E) JUDGMENT:
Personal:
Nurse: what will you do after getting discharged?
PATIENT: Don’t know.
INFERENCE:- personal judgment not intact
Social:
INFERENCE: He is cooperative and obeys the rules here.
Test:
NURSE: what will you do if your neighbor’s house catches fire ?
Patient: I will run away.
INTERENCE: Poor judgment.

1. INSIGHT:
Patient: When you came here?
Nurse: yesterday.
Nurse: Do you think you need treatment?
Patient: No , I want to die.
INFERENCE:
Insight absent.

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